Is the submission compliant?
Yes.
Then proceed to “Are the treatment plan and clinical documentation for the first clinical necessity review complete?”
No.
Then HNFS will request additional information, and the process will be pending (also referred to as “pend”) for up to 10 days. Note: For certain scenarios, the request will be canceled.
Proceed to “Has HNFS received the additional information?”
Has HNFS received the additional information?
Yes.
The timeline resets.
Proceed to “Is the additional information compliant with administrative requirements?”
No.
HNFS will cancel the process, and the process will stop here unless HNFS receives additional information after canceling the process.
Go to “Has HNFS received additional information after canceling the process?”
Has HNFS received additional information after canceling the process?
Yes.
The timeline resets. Go to “Is the additional information compliant with administrative requirements?”
Is the additional information compliant with administrative requirements?
Yes.
The timeline resets. Go to “Are the treatment plan and clinical documentation for the first clinical necessity review complete?”
No.
Then HNFS will request additional information, and the process will be pending (also referred to as “pend”) for up to 10 days. Note: For certain scenarios, the request will be canceled.
Go to Has “Has HNFS received the additional information?” and repeat the steps until process ends.
Are the treatment plan and clinical documentation for the first clinical necessity review complete?
Yes.
HNFS issues a coverage determination, and the process ends.
No.
Go to “Is a clinical consultation required?”
Is a clinical consultation required?
Yes.
HNFS will call the ABA provider to schedule a clinical consultation. The request will pend for up to 10 days.
Go to “Was the clinical consultation scheduled?”
No.
HNFS will request additional information, and the process will pend for 10 days to allow the ABA provider to make modifications and resubmit. Go to “Are the treatment plan and clinical documentation for the second clinical necessity review complete?”
Was the clinical consultation scheduled?
Yes.
HNFS conducts the clinical consultation with the ABA provider.
Go to “Are the treatment plan and clinical documentation complete after the clinical consultation?”
No.
HNFS cancels the process, and the ABA supervisor must contact HNFS to complete the consultation.
Has HNFS received a compliant treatment plan and clinical documentation for the second clinical necessity review?
Yes.
The timeline resets. Proceed to “Are the treatment plan and clinical documentation for the second clinical necessity review complete?”
No.
HNFS cancels the process, and the process ends.
Are the treatment plan and clinical documentation for the second clinical necessity review complete?
Yes.
HNFS issues a coverage determination, and the process ends.
No.
Go to “Is a clinical consultation required” and repeat the steps until the process is finished.
Are the treatment plan and clinical documentation complete after the clinical consultation?
Yes.
The timeline resets.
Go to “Are the treatment plan and clinical documentation for the second clinical necessity review complete?” and repeat the steps until the process is finished.
No.
HNFS will request additional information, and the request will pend up to 10 days.
Go to “Did HNFS receive the additional information from the clinical consultation?”
Did HNFS receive the additional information from the clinical consultation?
Yes.
The timeline resets.
Go to “Are the treatment plan and clinical documentation for the second clinical necessity review complete?” and repeat the steps until the process is finished.
No.
HNFS cancels the process.
Go to “Did HNFS receive the additional information after canceling the process?”
Did HNFS receive the additional information after canceling the process?
Yes.
The timeline resets.
Go to “Are the treatment plan and clinical documentation for the second clinical necessity review complete?” and repeat the steps until the process is finished.
